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Vesicovaginal and Ureterovaginal Fistula Workup

  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Dec 01, 2015
 

Laboratory Studies

If the presence of a vesicovaginal or ureterovaginal fistula is in doubt, vaginal secretions and fluid pooling in the vaginal vault should be sent for creatinine level evaluation. Serum creatinine should be drawn simultaneously, and that level should be compared with the fluid creatinine. If the fluid creatinine level is significantly higher than the serum creatinine, this confirms that the fluid is urine. If fluid creatinine test result is equivocal but a fistula is still suspected, proceed with a complete fistula workup, as discussed below.

Urinalysis and urine culture are used to rule out coexisting urinary tract infection.

Electrolyte panel (Chem 7) is used to evaluate renal function.

Complete blood cell (CBC) count is used to rule out systemic infection.

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Imaging Studies

Radiographic imaging should include intravenous pyelography (IVP) or CT urography to rule out coexisting ureterovaginal fistula or ureteral obstruction. When a ureter is involved in the margin of the vesicovaginal fistula, IVP may demonstrate a standing column of contrast within the ureter, extravasation of contrast around the distal ureter, or hydronephrosis.

Cystography often demonstrates contrast leaking from the fistula tract. This confirms the presence of vesicovaginal fistula.

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Other Tests

See the list below:

  • Double dye test
    • Frequently, the double dye test is useful for diagnosing vesicovaginal fistula.
    • In this test, the patient ingests oral phenazopyridine (Pyridium), and indigo carmine or methylene blue is instilled into the bladder via a urethral catheter. Pyridium turns urine orange, and methylene blue (or indigo carmine) turns urine blue.
    • A tampon is placed into the vagina. If the tampon turns blue, suspect vesicovaginal fistula. If the tampon turns orange, suspect ureterovaginal fistula. If the tampon turns blue and orange, suspect a combination of vesicovaginal and ureterovaginal fistulas.
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Diagnostic Procedures

See the list below:

  • Cystoscopy
    • Cystoscopy with concurrent vaginal speculum examination helps determine the location and size of the fistula in relation to the vaginal cuff, trigone, and ureteral orifices. In addition, it reveals the degree of inflammatory reaction and the number of fistulas present.
    • Most fistulas discovered after hysterectomy are located immediately behind the interureteric ridge and on the anterior vaginal vault.
  • Retrograde pyelography
    • This is the most definitive test to determine the presence of ureterovaginal fistula.
    • Retrograde pyelography must be performed if IVP findings are abnormal or if the fistula site is difficult to locate.
    • Performing bilateral retrograde ureteropyelography is often important because both ureters may be injured.
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Histologic Findings

If the fistulous tract is excised as part of the repair technique, the specimen should be sent for pathologic evaluation to review the histologic findings. Pathologic findings vary depending on the cause of the fistula and may include foreign body,[4] giant cell reaction, malignancy, or chronic inflammation.

Giant cell reaction may be present if a foreign body was part of the cause of the fistula (eg, a nonabsorbable suture ligature of a uterine vessel catching the vaginal cuff and the bladder wall).

Radiation-induced fistulas are due to late changes caused by the radiation. After cessation of radiation therapy, fibrosis occurs in the bladder lamina propria. As fibrosis occurs in the subepithelial tissues, hyalinization of the connective tissues occurs. Often, large bizarre fibroblasts, ie, radiation fibroblasts, are encountered. An obliterative arteritis may be observed in medium-to-small vessels. These vascular changes may result in atrophy or necrosis of the bladder epithelium, causing ulceration or the formation of fissures. Again, it is important to rule out local cancer recurrence, especially in the setting of prior radiation therapy.

Fistulas due to cervical carcinoma may demonstrate either squamous cell carcinoma or adenocarcinoma. Fistulas due to iatrogenic injury manifest as signs of acute and chronic inflammation. The presence of abundant neutrophils suggests an acute inflammatory response. In patients with chronic inflammation, the predominantly lymphocytic infiltrate is associated with macrophages. In addition, interstitial tissue fibrosis and necrosis may be present.

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Contributor Information and Disclosures
Author

Sandip P Vasavada, MD Physician, Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine, Center for Female Urology and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic

Sandip P Vasavada, MD is a member of the following medical societies: American Urological Association, Engineering and Urology Society, American Urogynecologic Society, International Continence Society, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Allergan and Axonics<br/>Received ownership interest from NDI Medical, LLC for review panel membership; Received consulting fee from allergan for speaking and teaching; Received consulting fee from medtronic for speaking and teaching; Received consulting fee from boston scientific for consulting.

Coauthor(s)

Raymond R Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Neurourology, Female Pelvic Health and Female Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Beachwood Family Health Center, and Willoughby Hills Family Health Center; Director, The Urothelial Biology Laboratory, Lerner Research Institute, Cleveland Clinic

Raymond R Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael Grasso, III, MD Professor and Vice Chairman, Department of Urology, New York Medical College; Director, Living Related Kidney Transplantation, Westchester Medical Center; Director of Endourology, Lenox Hill Hospital

Michael Grasso, III, MD is a member of the following medical societies: Medical Society of the State of New York, National Kidney Foundation, Society of Laparoendoscopic Surgeons, Societe Internationale d'Urologie (International Society of Urology), American Medical Association, American Urological Association, Endourological Society

Disclosure: Received consulting fee from Karl Storz Endoscopy for consulting.

References
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Vaginal view of vesicovaginal fistula.
Cystoscopic view of vesicovaginal fistula.
Cystogram of vesicovaginal fistula. Note the contrast extravasating from the bladder into the vaginal canal.
This patient developed a supratrigonal vesicovaginal fistula immediately over the right ureteral orifice after transabdominal hysterectomy for uterine fibroids. The right ureteral orifice has been cannulated with a ureteral catheter to prevent injury to the ureteral orifice during the fistula repair. A Foley catheter has been inserted into the bladder. A transvaginal repair was performed.
Percutaneous suprapubic tube is placed prior to repair of a supratrigonal vesicovaginal fistula.
The supratrigonal vesicovaginal fistula site is marked out.
Supratrigonal vesicovaginal fistula. Isotonic sodium chloride is injected into the anterior vaginal wall to facilitate hydrodissection.
Supratrigonal vesicovaginal fistula. A J-shaped incision is made, and the anterior vaginal wall is dissected off proximally and distally to the fistula. The fistula site is not excised. A generous flap is created anteriorly and posteriorly to the fistula site. Surgical sutures have been placed in the fistula to close the site.
Supratrigonal vesicovaginal fistula. Surgical sutures are tied, and the fistula is closed.
Supratrigonal vesicovaginal fistula. Reinforcing tissue layers are used to cover up the fistula site in a nonoverlapping fashion. In this case, peritoneum followed by pubocervical fascia was used.
Supratrigonal vesicovaginal fistula. Vaginal wall is closed.
 
 
 
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